Recently, many Americans have publicly become more politically and socially active, and healthcare professionals are no exception. Public activism raises the question of what obligations, if any, do healthcare executives have in taking a position on issues regarding the delivery of healthcare and health promotion?
Insight into this question lies within the context of ACHE’s Code of Ethics. As a condition of membership to ACHE, all members agree to adhere to the Code of Ethics. As noted in the ACHE web-based ethics toolkit, “ACHE believes the Code is integral to the practice of healthcare management.” The Code serves as the standard to guide members’ ethical decisions and actions. The Code, following a preamble, contains a breakdown of professional responsibilities to patients, the organization, employees, and the profession, and a substantive section on responsibilities to community and society. Within the context of the healthcare executive’s responsibilities to community and society are five specific obligations. This is a powerful component of the Code, calling executives to examine their own and their organization’s values and commit to taking a role in social responsibility.
Each specific obligation to the community and society is deserving of executives’ renewed consideration and self-examination. The Code does not direct what members should think, but what members should be thinking about. We briefly highlight this aspect of the Code of Ethics and offer some practical comments related to the specific obligations.
Reflections on the Responsibilities to Community and Society
“Work to identify and meet the healthcare needs of the community.” The statement is clear and meaningful for leaders of healthcare organizations. They are responsible for understanding the community’s needs and seeking to meet them. If leaders are going to meet the community’s needs, it’s important to fully understand what those needs are.
“Work to support access to healthcare services for all people.” This requirement also seems to be fairly routine, although it does raise questions about how far must the work of executives go to support the access of healthcare services to all people. Should healthcare executives be involved in lobbying legislatures, for instance, for the expansion of Medicaid or other types of insurance? To date, healthcare advocacy organizations, such as the American Hospital Association and several state-based hospital associations, have generally lined up behind Medicaid expansion, viewing it as having an impact on the bottom line if Medicaid payments replace uncompensated care. But we know that health insurance is only one step toward meaningful access to healthcare. Millions of low-income people, many of whom are insured by Medicaid, are searching for mental healthcare in a system in which many individual providers accept only commercial or out-of-pocket payments.
“Encourage and participate in public dialogue on healthcare policy issues and advocate solutions that will improve health status and promote quality healthcare.” Herein, the Code of Ethics calls upon executives to take an active stance as citizens on a potentially wide range of policy issues not only related to the delivery of healthcare but also health promotion. Current attention to social determinants of health underscores that relevant domains of healthcare and health policy may span housing, nutrition, transportation and zoning.
Hosting communitywide meetings and events on healthcare campuses may be one way to fulfill this part of the Code. Another may be taking on a more deliberate community organizing role in soliciting community input on federally mandated community health needs assessments. Even though ACHE does not advocate as an organization, the Code of Ethics calls members to individually consider the scope of their obligations.
Although some executives may feel uncomfortable publicly expressing their own healthcare-related policy views, publicly advocating for policies that are aligned with the organization’s mission, vision and values is a given. When in doubt, executives may rightly convene others to share their views and simply sit and listen.
“Apply short- and long-term assessments to management decisions affecting both community and society.” Such a standard carries an implicit requirement that administrators are able to ascertain the short- and long-term impacts of their choices on community and society. Doing so may be challenging given the far-reaching ripple effects of healthcare executives’ decisions. For instance, healthcare executives’ advocacy for health insurance expansion may be expected to deliver short-term expansions in access but may negatively impact the availability of public resources that could be committed to other social priorities. The full range of all impacts from a given action may not be understood, but making a habit of looking beyond quarterly and yearly time horizons can help executives meet this standard.
“Provide prospective patients and others with adequate and accurate information, enabling them to make enlightened decisions regarding services.” This standard raises provocative questions about the extent to which healthcare executives are obligated to provide prospective patients with information about costs and quality of recommended treatments, which in many markets is not standard practice.
Moreover, administrators may ask themselves what defines prospective patients. Are these only people who walk through the front doors of the clinic, office or hospital for assessment, or are they a larger set of people who might never consider receiving services?
Final Thoughts
This brief review of the ACHE Code of Ethics supports the understanding that healthcare executives have significant social responsibilities that parallel, and in some sense exceed, those of physicians. Dating back to the establishment of the ACHE Code of Ethics in 1941, healthcare executives have been expected to be leaders not only within their organizations but also in their communities and society.
To satisfy this important ethical standard, healthcare executives need to be well informed and possess accurate information about the many issues impacting the delivery of healthcare and the ability to foster the health of the community. Armed with current information, executives must reflect on their own perspectives on how best to support the access of healthcare for all people or their position on various healthcare policy issues. Available information will often be insufficient or inconclusive, in which case executives must be prepared to rely on the organization’s mission and values in decision making. In anticipation of such difficult choices, healthcare executives would be wise to explore these issues with other employees and stakeholders.
Of course, there are risks with public engagement in that some people may either disagree with your perspective or think you are overstepping your role. However, we believe the Code calls on healthcare executives not to be silent concerning important issues. The voice of the executive in the public dialogue is crucial. ACHE’s Code of Ethics calls on executives to examine their own and their organization’s values and commit to taking a role in social responsibility.
William A. Nelson, PhD, HFACHE, is a professor at Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, N.H. He also serves as an adviser to the ACHE Ethics Committee (william.a.nelson@dartmouth.edu).
Lauren A. Taylor is a doctoral candidate in health policy and management at Harvard Business School, Boston (ltaylor@hbs.edu).